A Story of the “Puritanical-Eater” (Orthorexia Nervosa): A Rare Case Report of How Obsessive Compulsive Disorder with Multiple Themes Led to Extremes of Malnutrition

Abstract

Orthorexia Nervosa is a terminology used to describe the combination of obsessive-compulsive disorder adversely affecting eating patterns in the absence of anorexia or bulimia. And unlike their counterparts, these patients are neither focused on losing weight nor are they fettered by their body shape and looks. Although this terminology is yet to be recognized by the American Psychiatric Association with vague criteria to describe this clinical entity, several cases across the world report a similar pattern of presentation. This case report describes one such encounter.

INTRODUCTION

Orthorexia Nervosa was first described by American physician Steve Bratman in 1997,[¹] which is an amalgamation of the term “orthos” which is defined in Greek terminology as “right” and orexis as “hunger.” Patients affected by the disorder often present with a severe obsession with the purity of their food, usually relating to the themes of health. Unfortunately, such “healthy” forms of eating often lead to obsession with the choice of food, leading to restriction in terms of choice or amount of food taken. This case report highlights a rare form of obsessive-compulsive disorder (OCD) where the obsessions disable the patient from acquiring proper nutrition as she gradually became more and more selective regarding her food intake. We also describe the laborious effort undertaken by a multidisciplinary team in a concerted effort to nurse her back to health. The interesting psychodynamic formulation that underlies her psychopathology is briefly highlighted as well.

CASE REPORT

Miss O is a 30-years-old Malay female who first presented to the emergency department on 2017 with complaints of repetitive hand washing behavior. She was given a psychiatric referral but did not turn up for the appointment. She returned to the clinic on 2021, brought by a concerned mother. The treating team was shocked as she appears to be very emaciated, weighing only 25 kg. Although she was of short stature with a height of 131 cm, her body mass index (BMI) was 13.8 which was dangerously low. She was reluctant to step into our clinic and kept both her hands suspended precariously at chest level. She appeared to be fearful of getting in contact with any surfaces. Although we cordially beckoned her to have her seat, she was hesitant. Her mother, knowing better of her proceeded to meticulously cover the seat with sheets of newspaper. Still visibly uncomfortable, it was then when she reluctantly took her seat. The treating doctor could not help but notice that her bilateral lower limbs were filled with a mixture of healing and fresh ulcers. Her previously regular menstrual cycles had ceased for almost a year and her peripheries were cold and clammy.

According to Miss O, her OCD symptoms had worsened over the past 2 years and after much persuasion by her mother decided to return to seek treatment. On top of her hand-washing behavior in which she would spend almost 8 h in the bathroom every day, she also had a habit of checking her possessions repeatedly. But what was most disturbing was the fact that she developed a new form of obsession; being extremely selective of food. Miss O was initially very defensive and dismissive regarding her food intake but eventually revealed that it began 2 years ago after she developed several bouts of gouty arthritis affecting her lower limbs. A local general practitioner advised her against excessive intake of nuts and seafood which she previously enjoyed as it could aggravate the inflammation of her lower limbs.

Before her illness, she consumed a variety of traditional Malay food and loved poultry and eggs cooked with “gulai lemak” which was a local delicacy with the occasional indulgence in cheesecakes. After suffering from arthritis, she decided to reduce her food intake substantially, eating only once per day. When she did, she ate only a small amount of plain rice and lean chicken meat which she approximated one portion as being half a palm full. When she was hungry, Miss O would curb her hunger by drinking plain water. She did not impart any history to suggest that she was affected by fear of gaining weight or being fettered by her general appearance.

We decided to treat Miss O as an inpatient because of the deterioration of her condition. Although her blood investigations and vital parameters were normal, there were several issues to be addressed. The attending dietician opined that the effort to help her gain some healthy body weight had to be gradual. Miss O’s nutritional rehabilitation program would be treated similar to those of Anorexia Nervosa. We would set a target weight gain of 500 g per week. She was also treated with Fluoxetine and Risperidone to address her OCD symptoms. The team also collaborated with the clinical psychologist to elucidate the psychological issues which could have led to such a disorder.

Miss O’s parents did not impart any significant developmental history to note during her childhood history. She performed fairly in her studies and was on par with her siblings, passing major examinations with modest results. However, they did acknowledge that Miss O was more quiet, introverted, and used to keep to herself rather than mingling with others.

Miss O, being a shy woman was very guarded regarding her history, dismissing open and close-ended questions with simple answers such as “don’t know or can’t remember.” We suspected that there was some form of repressive defense mechanisms at play in this context. During her 2 weeks stay in our ward, rapport gradually grew and we managed to glean some insights about some salient life events. During primary school, she recalled being bullied as a child. Miss O was ostracized by children of her age owing to her quiet demeanor. Her slightly short stature also became the object of ridicule. She recalled, albeit with some initial reluctance, several instances where she was locked in the toilet by a group of bullies. They would lock her in darkness for hours. At that moment she felt helpless and could do nothing but cry. Although she was rescued hours later, the encounter instilled in her the sense that no one would be there to help her. Being a shy and petite lady, to begin with, she retreated into herself and became quiet, keeping most of her troubles to herself.

Despite the distressing themes surrounding the account, we noted the look of indifference as she spoke and postulated that some defense mechanism of “isolation of affect” was at play. Miss O also highlighted an event where she was preparing for a major examination. She aspired to score well as all of her siblings were high achievers. A few hours before her examination, she realized to her horror that she had forgotten to bring her identification card. Although she was not denied entry to the examination, Miss O said that she was so emotionally shaken that she failed to perform. She developed a habit of checking; surreptitiously inspecting doors to ensure that they were locked or if the gas stove was turned off ten times in a day. She felt compelled to do so to prevent further mishaps.

At the age of 27, Miss O developed bilateral eczematous lesions over the dorsum of her foot. She started washing both her legs several times a day as she perceived herself to be unclean. Multiple instances of washing in a day left the skin of her leg brittle with angry red weal’s which eventually ulcerated. As the condition of her legs worsened, she became more and more stringent with her dietary intake, resulting in severe weight loss. She believed that her foot could only be cured via puritanical eating, hence the drastic change in eating behavior.

Throughout her stay in the ward, she agreed to eat the food that was provided to her, albeit with some degree of initial hesitance. The team provided her with Exposure Response Prevention (ERP) to help her cope with her fear of contamination. She demonstrated a favorable response to her medications and was subsequently discharged with the working diagnosis of OCD with poor insight. Keeping the informal yet possible presence of Orthorexia in mind, the team decided to peruse several works of literature concerning description and treatment for the disorder which would be presented in the section below.

DISCUSSION

Although not formally recognized in the Diagnostic and Statistical Manual, awareness about Orthorexia is on the rise. The term “Orthorexia” was coined in 1998 to describe a disorder of excessive obsession with “healthful” eating which paradoxically leads to overt consequences.[²] Although being aware of and concerned with the nutritional quality of the food may appear to be beneficial, people with Orthorexia become so fixated on so-called ‘healthy eating that it becomes detrimental. Without formal diagnostic criteria, it’s difficult to get an estimate on precisely how many people have Orthorexia, and whether it’s a stand-alone eating disorder, a type of existing eating disorder like anorexia, or a form of OCD. At the time of writing, there is no international prevalence rate established for this particular disorder. A large-scale national study conducted in Germany,[³] noted the prevalence to be as high as 6% in their populace but acknowledged that it may be over diagnosed given the poor diagnostic criteria to specifically delineate the disorder. Researchers also noted a strong association between Orthorexia with depression. An Australian study utilizing a similar design also revealed a near equal prevalence of 6.5%[⁴] whilst US counterparts reported a lower rate of 1%.[⁵]

The National Eating Disorder Association (NEDA) proposed the following sign and symptoms as the possible diagnostic criteria of Orthorexia nervosa.[⁶] They postulated that the individual would demonstrate an increase in concern about the health-related consequence of food ingredients and begin cutting out an increasing number of food groups e.g., (all sugar, all carbs, all dairy, all meat, and all animal products). This is followed by an inability to eat anything but a narrow selection of foods that are deemed “healthy” or “pure.” They also develop an unusual interest in what others are eating, spending hours per day thinking about what food might be served at upcoming events. There are high levels of distress when “safe” or “healthy” foods aren’t available and may obsessively follow food and “healthy lifestyle” related topics on social platforms.[⁶] NEDA reserves the criteria that body image concerns may or may not be present and noted that most patients with Orthorexia also have OCD.

There is a growing number of case series and reports worldwide with reports of patients concomitantly suffering from OCD and eating disorders. One such study reports a 28-year-old man from the west who only consumed vitamins and dietary supplements.[⁷] There was substantial weight loss but there was no preoccupation with bodily images or fear of weight gain. Compared to Miss O, his obsessions were less pronounced. The patient responded well to a combination of Olanzapine and a nutritional rehabilitation program, recovering uneventfully.

A case series of four women subjects affected by the disorder was described by Rania etal.[⁸] using Dunn and Bratmann’s criteria.[⁹] They noted overlapping themes of obsessive focus on “healthy” eating followed by compulsive behavior with mental preoccupation regarding food intake. These behaviors would subsequently lead to malnutrition and interpersonal impairment with satisfaction gained from “self-defined” healthy eating behavior. All four patients recovered after being treated with a nutritional rehabilitation program and two patients responded to cognitive behavioral therapy.[⁸] The author did not describe any form of pharmacotherapy used in this case series.

It is important to take note that several differential diagnoses may mimic the condition portrayed in the case of Miss O. First of all was the fact that she made significant improvement with a combination of antipsychotics and antidepressants within 3 weeks. It would therefore be worthwhile to consider the possible differentials such as psychosis due to Schizophrenia or major depressive disorder as contenders. Furthermore, the patient’s low BMI may also contribute to her difficulty to recall recent and distant past events versus psychological repression. A paper by Arvanitakis etal. in 2018 discussed the possibility of the extremes of BMI (low or high) causing transient or lasting effects on cognition, especially in recall.[¹⁰]

We noted that selective serotonin reuptake inhibitor and a combination of low-dose antipsychotics aided the recovery of Miss O. We also recommend cognitive behavioural therapy (CBT) to correct misperceptions and negative thoughts about food intake. In the case of Miss O, ERP was used to treat her fear of contamination, beginning with touching the sanitized surface, door knobs, and finally a clean floor. Her sessions were supervised by a psychiatrist who accompanied her throughout the sessions, touching the surfaces together as a gesture to disprove her negative thoughts and at the same time conveying the message of warmth that she was not alone in her struggles.

CONCLUSION

Dealing with OCD with multiple themes leading to severe malnutrition is rarely encountered. However, we discovered that prompt nutritional rehabilitation [Appendix A], coupled with pharmacotherapy and psychotherapy (CBT and ERP) was efficacious in the case of Miss O. It must be kept in mind that several differential diagnoses such as organic causes and psychotic disorders could lead to similar presentations. Readers are therefore advised to exercise discretion when synthesizing results from this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.